Pain is a significant problem for various patients postoperatively. Apart from alleviating discomfort, pain control measures facilitate clinical effect. Epidural infusion is one of the pain control measures. As a result, this paper will discuss the rationale behind the use of epidural infusion in Mr. Johnston who has just undergone pneumonectomy. Priority assessment and nursing care as well as management of complications.
Rationale of epidural infusion in care of Mr. Johnston
Epidural infusion is significant for continuous alleviation of pain. This is because of its antagonistic effect on the pathophysiology of pain. According to Keogh (2007), pain occurs due to deep, shallow or light pressure. Deep pressure is like a cut while shallow pressure is like a prick. On the other hand, light pressure is like a pinch. Deep pressure will stimulate the parcinian nerves while shallow will irritate the messinian. Besides, light pressure will stimulate nerves endings. The stimulated nerves will send impulse to the brain (Dolin, 2002). The brain will react to this impulse by sending pain sensation to the body.
The person will then experience pain. Mr. Johnston is experiencing deep, shallow and light pain. Deep pain is because of pneumonectomy. Shallow pain is because of the intravenous cannula that is insitu as well as the indwelling epidural infusion catheter. Lastly, light pain is because of the indwelling catheter. Therefore, Mr. Johnston will greatly benefit from epidural infusion. This is because the epidural infusion will block the transfer of nerve impulse to the brain (Manabe, 2004). As a result, the brain will not receive impulses from the nerves. Consequently, the brain will not send nerve stimulus to his body. This means that Mr. Johnston will not experience pain. Therefore, he will have a very low pain score. It is evident that epidural infusion will keep Mr. Johnston comfortable via alleviation of pain.
The main complications of pain postoperatively include immobility, neurogenic shock and anxiety. In a recent research, Fawcett (2009) explains that immobility which is a complication of postoperative pain cause constipation, respiratory complications and risk of impaired skin integrity. Constipation occurs because immobility decreases intestinal motility. As a result, the ingested food remains static in the intestines. This stasis interferes with the digestion processes and cause constipation. Moreover, immobility causes respiratory complications. This is because when a person is immobile, secretions accumulate in the respiratory system (Penny, 2007).
As a result, the person present with ineffective airway clearance, impaired gaseous exchange and breathing difficulties. Furthermore, immobility, which is a complication of pain, put the patient at risk of impaired skin integrity. This is because when one does not move, there is exertion of pressure on the protruding parts of the body. As exertion of pressure continue, the person is likely to have a skin break. Swearingen (2009) explains that postoperative pain cause neurogenic shock. This is because pain interferes with parasympathetic and sympathetic nerves. As a result, the neurogenic shock exposes a person to hypostatic pneumonia and renal failure.
Finally, postoperative pain causes anxiety (Wilmore, 2002). When the person is anxious, he is likely to suffer from stress that can progress to depression and interfere with the recovery process. Therefore, if Mr. Johnston is on epidural infusion, he will escape these pain complications thus, quick recovery.
On the other hand, epidural infusion has some risks associated with it. To begin with, the patient is at risk of infection (Keogh, 2007). This is because the insertion site of epidural infusion acts as a portal of entry for the microorganism that causes diseases. To alleviate this risk, the insertion site should be dressed aseptically. Secondly, epidural infusion can cause hypotension. This is because of the vasodilatation effect of analgesia. Therefore, blood pressure monitoring is imperative for early detection and management of hypotension. Thirdly, the epidural analgesia can cause urine retention (Smith, 2011). This is because the analgesia prevents the sensation of nerves that supply the bladder.
As a result, the bladder muscles relax. The relaxation of the bladder muscles causes urine retention. The prevention of urine retention is via the use of an indwelling catheter. Fourthly, epidural analgesia can causes pruritus. This is due to the injury of the nerves and it clears as the healing process take place. Additionally, the patient can benefit from antihistamines. Fifthly, epidural analgesia put the patient at risk of respiratory depression (Manabe, 2004).
This is because epidural analgesia medication depresses the respiratory system. To alleviate the respiratory depression, the nurse can give the patient an antidote. Lastly, epidural infusion put the patient at risk of post-dural puncture headache, epidural hematoma, abscess and neurological damages. The nurse can prevent these risks by vigilance monitoring of the patient. Therefore, it is safe for Mr. Johnston to be on epidural infusion. This is because the nurse can prevent or manage the risks associated with it.
Finally, epidural infusion is important for the care of postoperative pain of Mr. Johnston because of the benefits associated with it. To begin with, it improves pain control. In a survey about postoperative pain, Wheately (2003) reports that, ninety percent of the patients on epidural infusion recorded a pain score of zero to three. This shows that epidural analgesia is a good pain controller post operatively. This is because of its ability of blocking the nerves that send pain impulse to the brain. Besides, epidural infusion alleviates pain for a long period because of the slow release into the body. Secondly, epidural infusion decreases pulmonary complications (Swearingen, 2007).
This is because it alleviates pain hence, increasing the mobility of a person. When a person is mobile, chances of hypostatic pneumonia reduce. Additionally, a person who is free of pain is likely to breathe well thus an improved gaseous exchange process. Lastly, epidural analgesia reduces the patient’s level of anxiety. When anxiety level is low, there is a high probability of a positive outcome. Therefore, Mr. Johnston will experience the benefits of epidural infusion thus fast recovery.
Priority assessment and nursing care
I would begin by vital signs assessment. This is because epidural infusion alters the body temperature, respiration, pulse rate and blood pressure (McCabe, 2006). I would assess the ventilation and breathing pattern. Ventilation assessment is important in determination of airway patency (Swearingen, 2007). In case of a blocked airway, I would position the patient and suck the accumulated secretions. This is because positioning opens the airway while sucking clear it (Heitkemper, 2010).
In case of ineffective breathing pattern, I would administer oxygen because Bunker (2010) explains that oxygen assist in gaseous exchange process thus, effective breathing patterns. I would then take the blood pressure and pulse rate of the patient. This is because an abnormal blood pressure, heart or pulse rate is an indication of defective cardiovascular system (Workman, 2009). Additionally, epidural infusion usually depresses the cardiovascular center at the brain and the patient can present with hypotension, tachycardia or tachpnea (Park, 2007).
According to a research done, Pearce (2011) argues that epidural infusion can cause either hypertension or hypotension. Hypertension occurs because epidural infusion causes urine retention with subsequent accumulation of fluids in the body (Wilmore, 2002). On the contrary, hypotension occurs because the analgesia medication relaxes the body muscles with subsequent vasodilatation leading to inadequate volume (Manabe, 2004). Therefore, in case the patient has retained urine, I would catheterize.
This will alleviate the incidence of hypertension. Moreover, in case the patient present with hypotension I would administer intravenous fluids. The intravenous fluids will increase the volume thus alleviating hypotension. Finally, I would monitor the input and output of the patient. The monitoring is imperative because it would help in early detection and management of impaired fluid volume, which usually interfere with blood pressure (Myers, 2010).
In case the patient has tachycardia, I would stop the infusion. This is because Kehlet (2003) explains that the adrenalin in epidural infusion medication has an inotropic effect thus, it increase the heart rate. Lastly, I would take the temperature. This will provide the base line data to determine onset of infection. When the vital signs of the patient become stable, I would proceed to pain assessment.
In a recent study, Licker (2002) concluded that epidural infusion can fail and as a result the patient experience pain and discomfort. Therefore, I would assess the pain level of the patient by use of pain score. In case the patient score zero to three, it means the epidural analgesia is successful. A score of more than four is an indication of severe pain (Myers, 2010). This means that the patient is not experiencing the benefits of epidural infusion. Therefore, I would increase the amount of epidural infusion medication. This is because a tolerance dosage is likely to cause a positive effect (Manabe, 2004). I would keep on observing the patient for any sign of discomfort related to pain. Once the patient is free from pain, I would perform the neurological assessment.
Neurological assessment is important in determining the level of consciousness of the patient. This is because continuous epidural infusion can be toxic to the central nervous system hence loss of consciousness (Licker, 2002). I would assess the patient’s level of consciousness by use of a Glasgow coma scale. This involves the assessment of verbal, motor and eye opening (McCabe, 2006). In case the patient is unconscious, I would stop the infusion and position the patient appropriately. According to Powell (2010) appropriate positioning of an unconscious patient, facilitate faster recovery. After the patient is conscious, I would perform a musculoskeletal assessment.
Musculoskeletal assessment involves evaluation of the patient mobility status. This is because a potent epidural infusion should increase the mobility of the patient (Heitkemper, 2010). Mobility assessment is important because immobility put the patient at risk of constipation, pressure ulcers and respiratory complications (Wilmore, 2002). In case of immobility, it means that the dosage of epidural infusion is not adequate to produce the desired effect (Powell, 2009). This is because epidural infusion usually facilitates faster mobility postoperatively. Therefore, I would increase the amount of epidural infusion medications. Once the patient is mobile, I would perform a psychological assessment.
Psychological state assessment assists the nurse to establish the anxiety level of the patient. In a research by Pearkins (2002), a positive correlation exists between pain and anxiety. This means that a person experiencing pain is likely to be anxious. Anxiety has a negative impact on the clinical outcome of the disease. However, epidural infusion assuages the anxiety via pain alleviation. In case the patient is calm, it means that the epidural infusion is effective. Therefore, I would proceed and assess the incision sites.
Assessment and care of incision sites is important because it help in prevention of infection (Bunker, 2010). This is because incision sites act as portal of entry for microorganisms (Powell, 2009). Therefore, I would begin by assessing the incision sites to determine if they are bleeding. In case of bleeding, I would arrest it via pressure application and use of anticoagulant antagonists like vitamin K and Proctamine Sulphate (Kehlet, 2003). I would then change the dressings aseptically and leave the patient comfortable. According to Pearkins (2002), aseptic technique minimizes the introduction of microorganisms into the incision site. After the assessment and care of incision sites, I would assess the knowledge level of the patient.
Park (2007) explains that knowledge assessment of postoperative patients who are on epidural infusion is imperative because it determine the level of the coping mechanism of the patient. I would assess the knowledge level of the patient concerning pain, infection and complications of epidural infusion. In case of knowledge deficit, I would educate the patient on what to expect while on epidural infusion. For instance, he should not have pain, fever, nausea, vomiting and fatigue. I would also inform the patient about the importance of keeping the incision sites clean and dry. Education will help the patient to know what to do and expect while on epidural infusion (Bunker, 2010).
Alleviation of complication
Mr. Johnston presentation of a blood pressure of 85/50, a warm feeling and dry skin with a temperature of 36.5 is a sign of inadequate fluid volume (Bunker, 2010). This is because inadequate fluid volume causes hypotension and a patient present with a blood pressure that is less than 90/60. Additionally, inadequate volume reduces the skin turgidity and the person present with dehydration. Finally, inadequate volume causes vasoconstriction of the blood vessels and the patient present with a warm touch and a core temperature of around 37. The goal of management is to restore the blood volume.
I would begin by taking the blood pressure of Mr. Johnston. This is because the initial blood pressure will act as a base line for the evaluation of intervention (Kneedler, 2008). I would then administer intravenous fluids. This is because intravenous fluids usually replace the lost volume faster that oral intake (Park, 2007). Nonetheless, I would encourage Mr. Johnston to increase the amount of oral fluid intake. This is because the oral intake will potentiate effect of intravenous administration. I would monitor the input and output of Mr. Johnston. This is important in determination of the cause of fluid volume deficit (Manion, 2011).
For instance, if the output is more than the normal range, it means that Mr. Johnston has a problem with the urinary system. Therefore, I would refer him for further management. On the other hand, a decreased input would mean that there is need of increase in the oral intake and intravenous infusion. Finally, I would monitor the vital signs of Mr. Johnston to evaluate the effectiveness of the intervention.
Complication of epidural infusion
The main complication of epidural infusion is respiratory discomfort (Ladwig, 2006). This complication comes about because of the depressive effect of epidural infusion medications on the respiratory system. The depression of respiratory system causes an increase in respiration rate. This is a physiological reaction to decreased oxygen level in the body (Kehlet, 2003). Besides, it is the reason why Mr. Johnston presented with a respiration rate of 26. With time, the body physiologic mechanism fail and the person present with low respiration. This is the reason why Mr. Johnston presented with subsequent shallow respiration. Finally, carbon dioxide accumulates in the circulatory system and the brain lack oxygen. The lack of oxygen causes headache and fatigue. This is the reason behind Mr. Johnston complain of headache.
The goal of nursing care is to increase oxygen level in the body. I would begin by positioning Mr. Johnston. The positioning facilitates free movement of air in and out of the respiratory system (Eldridge, 2008). I would then administer oxygen via nasal prongs. Oxygen administration assists in the proper functioning of the respiratory system thus alleviation of the effect of accumulated carbon dioxide. I would then assess the vital signs of Mr. Johnston paying close attention to the respiration rates. The assessment will assist in evaluation of the effectiveness of the care. Incase Mr. Johnston condition does not respond to the aforementioned interventions, I would stop the epidural infusion. I would then refer him to the anesthesiology for further management.
In conclusion, epidural infusion is important for Mr. Johnston as it relieve the postoperative pain. Therefore, it alleviates complications associated with pain leaving Mr. Johnston comfortable. Additionally, it has risks that one can prevent and the benefits outweigh the complications. Therefore, Mr. Johnston will greatly benefit from the epidural infusion.
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